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N ORTH D A KOTA D E L T A D E N T A L P P O SM P L U S P R E M I E R PAT H F I N D E R P L A N A N D PAT H F I N D E R VALUE PLAN Direct Benefits Inc. • 325 Cedar Street • Suite 800 • St Paul, MN 55101 www.directbenefits.com Administered and Underwritten by Delta Dental of Minnesota SM Delta Dental PPO Plus Premier Pathfinder Plan N ORT H D A K O TA Whether you’re purchasing group dental insurance for the first time or looking for a new plan, it’s hard to know which path to choose. Let us expertly guide you through the process. A plan that puts you on the right path • For groups with 2-99 employees. • Offered on a contributory or voluntary basis. • Two-year rates available for price stability. Comprehensive benefits • 100% coverage of preventive care with no waiting periods. • Strong coverage for basic and major services. • Optional child and/or adult orthodontic coverage available. • Generous calendar-year maximums up to $3,000 and choice of low deductibles. - Marketed exclusively by Direct Benefits Inc., a nationwide brokerage now serving more than 6,000 independent agents. Two of the largest networks in the state • The Delta Dental PPO network is one of the largest PPO networks statewide. • Delta Dental Premier is one of the state’s largest networks overall, with 74% of North Dakota dentists participating. Unsurpassed service • Direct Benefits is there for you every step of the way, from pre-enrollment through implementation and beyond. • Delta Dental processes the average claim in just over one day, with almost 100% claims processing accuracy. See any dentist or specialist • Receive the strongest coverage and greatest savings at Delta Dental PPOSM network dentists. • When seeing Delta Dental Premier® network dentists, savings remain strong, but some coverage amounts are less than at Delta Dental PPO network dentists. When seeing non-network dentists, coverage is the same as the Delta Dental Premier network, although balance billing applies. Advantages to seeing a network dentist include: No balance billing – Members won’t be billed for the difference between the actual procedure charge on covered services and what the plan allows. With non-network dentists, members are responsible for the balance of the bill. No paperwork – Network dentists bill us, and we pay them directly. Members choosing non-network dentists may have to submit their own claims. Learn more about the Pathfinder Plan Call Direct Benefits Inc. at 651-649-3503 or 1-800-620-5010, visit directbenefits.com or e-mail proposals@directbenefits.com. Direct Benefits Inc. • 325 Cedar Street • Suite 800 • St Paul, MN 55101 www.directbenefits.com Underwritten and administered by Delta Dental of Minnesota, a leading dental benefits provider for 45 years, serving 3.8 million members. PATHFINDER PLAN Delta Dental PPOSM Network Delta Dental Premier® Network Non-Delta Dental Dentists 100% 100% 100% 80% 80% 80% Oral Surgery Services: basic extraction of erupted tooth or exposed root, surgical removal of erupted tooth, impacted teeth and tooth roots 55% 50% 50% Endodontic Services: pulpal therapy, root canal therapy, pulpotomy 55% 50% 50% Periodontal Services: non-surgical and surgical periodontal care 55% 50% 50% optional treatment optional treatment optional treatment 55% 50% 50% 55% 50% 50% SERVICE Diagnostic and Preventive Services no waiting period BENEFIT DESCRIPTION Oral evaluations/check-ups, X-rays, dental cleanings, fluoride treatments Basic Restorative Care & Services: amalgam (silver) fillings, sealants, space maintainers, palliative treatment for emergencies Basic Services no waiting period Coverage for Composite Resin (white) Fillings as Basic Services: Optional with 5% premium increase Coverage of Endodontic and Periodontal as Basic Services: Optional with 5% premium increase Basic Services 6-month waiting period Complex or Major Services 12-month waiting period Restorative Care Services: posterior composite resins, inlays onlays, crowns and crown repairs(*) Prosthetic Services: removable prosthetic services –dentures and partials (*) (**), fixed prosthetic services–bridges (*) (**), repairs–removable and fixed Implants Orthodontics– optional 12-month waiting period. No deductible applies. 50% coverage up to $1,000, $1,500 or $2,000 lifetime maximum. Orthodontic coverage for dependent children ages 8 through 18. Available for groups of 5+ enrolled employees. Adult orthodontics available for groups of 10+ enrolled employees — 12-month waiting period, 50% coverage up to $1,000 lifetime maximum. Deductible Employer chooses: $0/0, $25/75, or $50/150 per person/family per calendar year for basic and major services Annual plan maximum $1,000 per person/per calendar year. Options available for $1,250, $1,500, $2,000, $2,500 and $3,000 maximums. Optional Treatment– Member receives the amalgam benefit for the least costly commonly performed course of treatment. * Coverage does not include the following crown or bridge services: buildups, pins, posts and cores. ** Missing-tooth exclusion applies during the first 24 months of coverage. See underwriting guidelines for explanation of takeover benefits. Claim payments are subject to review. We strongly recommend a pre-estimate for implants and all major services. This is a summary only. For complete details, refer to your Dental Benefit Plan Summary. Delta Dental is a registered mark of Delta Dental Plans Association (“DDPA”). Delta Dental of Minnesota is an independent nonprofit dental services company and is an authorized licensee of the Delta Dental Plans Association of Oak Brook, Illinois. Direct Benefits Inc. is not an authorized licensee of DDPA. Nothing contained in this statement, or set forth in this document, is in any way meant to imply or suggest that the Pathfinder product or any of Direct Benefit Inc.’s products or services are sponsored, approved, endorsed or recommended by DDPA. PATH.199.13 Administered and Underwritten by Delta Dental of Minnesota SM Delta Dental PPO Plus Premier Pathfinder Value Plan N ORT H D A K O TA The Pathfinder Value Plan incorporates the great features found in our Pathfinder Plan, but designed for maximum cost-effectiveness by balancing a slightly larger up-front lifetime deductible with strong coverage at extremely competitive rates. Two of the largest networks in the state • The Delta Dental PPO network is one of the largest PPO networks statewide. • Delta Dental Premier is one of the state’s largest networks overall, with 74% of North Dakota dentists participating. A plan that puts you on the right path • For groups with 2-99 employees. • Offered on a contributory or voluntary basis. • Two-year rates available for price stability. Unsurpassed service • Direct Benefits is there for you every step of the way, from pre-enrollment through implementation and beyond. • Delta Dental processes the average claim in just over one day, with almost 100% claims processing accuracy. Comprehensive benefits • 100% coverage of preventive care with no waiting periods. • Strong coverage for basic and major services. • Optional child and/or adult orthodontic coverage available. • Generous calendar-year maximums up to $3,000 and choice of low deductibles. See any dentist or specialist • Receive the strongest coverage and greatest savings at Delta Dental PPOSM network dentists. • When seeing Delta Dental Premier® network dentists, savings remain strong, but some coverage amounts are less than at Delta Dental PPO network dentists. When seeing non-network dentists, coverage is the same as the Delta Dental Premier network, although balance billing applies. Advantages to seeing a network dentist include: No balance billing – Members won’t be billed for the difference between the actual procedure charge on covered services and what the plan allows. With non-network dentists, members are responsible for the balance of the bill. No paperwork – Network dentists bill us, and we pay them directly. Members choosing non-network dentists may have to submit their own claims. Learn more about the Pathfinder Value Plan Call Direct Benefits Inc. at 651-649-3503 or 1-800-620-5010, visit directbenefits.com or e-mail proposals@directbenefits.com. Direct Benefits Inc. • 325 Cedar Street • Suite 800 • St Paul, MN 55101 www.directbenefits.com PATHFINDER VALUE PLAN Delta Dental PPOSM Network Delta Dental Premier® Network Non-Delta Dental Dentists 100% 100% 100% 80% 80% 80% Oral Surgery Services: basic extraction of erupted tooth or exposed root, surgical removal of erupted tooth, impacted teeth and tooth roots 55% 50% 50% Endodontic Services: pulpal therapy, root canal therapy, pulpotomy 55% 50% 50% Periodontal Services: non-surgical and surgical periodontal care 55% 50% 50% optional treatment optional treatment optional treatment 55% 50% 50% 55% 50% 50% SERVICE Diagnostic and Preventive Services no waiting period BENEFIT DESCRIPTION Oral evaluations/check-ups, X-rays, dental cleanings, fluoride treatments Basic Restorative Care & Services: amalgam (silver) fillings, sealants, space maintainers, palliative treatment for emergencies Basic Services no waiting period Coverage for Composite Resin (white) Fillings as Basic Services: Optional with 5% premium increase Coverage of Endodontic and Periodontal as Basic Services: Optional with 5% premium increase Basic Services 6-month waiting period Complex or Major Services 12-month waiting period Restorative Care Services: posterior composite resins, inlays onlays, crowns and crown repairs(*) Prosthetic Services: removable prosthetic services –dentures and partials (*) (**), fixed prosthetic services–bridges (*) (**), repairs–removable and fixed Implants Orthodontics– optional 12-month waiting period. 50% coverage up to $1,000, $1,500 or $2,000 lifetime maximum. Orthodontic coverage for dependent children ages 8 through 18. Available for groups of 5+ enrolled employees. Adult orthodontics available for groups of 10+ enrolled employees — 12-month waiting period, 50% coverage up to $1,000 lifetime maximum. Deductible $100 per person (lifetime) Annual plan maximum $1,000 per person/per calendar year. Options available for $1,250, $1,500 and $2,000, $2,500 and $3,000 maximums. See underwriting guidelines for explanation of takeover benefits. Optional Treatment– Member receives the amalgam benefit for the least costly commonly performed course of treatment. * Coverage does not include the following crown or bridge services: buildups, pins, posts and cores. ** Missing-tooth exclusion applies during the first 24 months of coverage. Claim payments are subject to review. We strongly recommend a pre-estimate for implants and all major services. This is a summary only. For complete details, refer to your Dental Benefit Plan Summary. Delta Dental is a registered mark of Delta Dental Plans Association (“DDPA”). Delta Dental of Minnesota is an independent nonprofit dental services company and is an authorized licensee of the Delta Dental Plans Association of Oak Brook, Illinois. Direct Benefits Inc. is not an authorized licensee of DDPA. Nothing contained in this statement, or set forth in this document, is in any way meant to imply or suggest that the Pathfinder product or any of Direct Benefit Inc.’s products or services are sponsored, approved, endorsed or recommended by DDPA. PATH.201.13 Administered and Underwritten by Delta Dental of Minnesota Participation Guidelines — Pathfinder Plan and Pathfinder Value Plan Designed for Groups of 2-99 Eligible Employees N OR T H D A KOTA GROUP PARTICIPATION REQUIREMENTS ELIGIBLE EMPLOYEE PARTICIPATION REQUIREMENTS Participation guidelines apply according to the number of employees enrolling. — If coverage is initially waived, a qualifying event must occur to gain coverage. — No open enrollment for groups of 2-4 employees and no late enrollees, unless the employee has a change of status or qualifying event. — If an eligible employee drops coverage, he/she may not re-enroll at anytime unless a qualifying event occurs. Eligible Employee — Defined as actively at work for a minimum of 20 hours per week on a regular basis. — Full-time employees on a seasonal or temporary basis are not eligible. — Active employees age 65 + may be enrolled the same as any other eligible employee. Eligible Dependents — Spouses of eligible employees. — Dependent children to age 26 are eligible for coverage. If a dependent child is disabled prior to age 26, they remain eligible for coverage after age 26. Spouses — Both Employees of Same Employer Group — Spouses who are both employees of the same employer may each enroll in only one contract. — Neither spouse may be enrolled on both an individual and a family or employee plus spouse contract. — Both are eligible to be enrolled on separate individual “employee- only” contracts. Eligible Retirees — Retirees are eligible for coverage provided they had dental coverage with another carrier in a takeover situation at the time of retirement and elected to continue coverage. Retirees are not covered in the following situations: — If the retiree was not covered at the time of retirement, or they were not already covered as a retiree by another carrier in a takeover situation. — If the retiree drops their coverage, they may not re-enroll at a later date. — Retirees may not add dependents to their coverage who were not covered on the retiree’s employee plan at the time of the employee’s retirement. Domestic Partners — Groups of any size may request domestic partners coverage (same-sex and/or opposite sex). For groups with 2-4 employees enrolled: — One-time enrollment. For groups with 5+ employees enrolled: — Annual open enrollment. — To be in this sizeband, a minimum of 5 employees must enroll, and enrollment must consist of at least 20% of all eligible employees and 20% of dependents not covered by another dental plan. Waiting Periods and Takeover Benefits: Waiting Periods Waived for Prior Comparable Coverage If a group has at least 12 continuous months of prior comparable coverage, and no gap between that coverage and the Pathfinder effective date, all members of the group will receive a waiver of Pathfinder waiting periods, with the following exceptions: The waiver does not apply to employees/ dependents who join the group or enroll for Pathfinder coverage after the initial Pathfinder effective date. Credit of $100 Lifetime Deductible If a group has at least 12 months continuous coverage with a $100 lifetime deductible on its prior dental plan and converts to a Pathfinder plan with a $100 lifetime deductible, members of the group will receive credit for the $100 deductible, with the following exceptions: The credit does not apply to employees/dependents who (a) were not enrolled in the group’s prior dental plan or (b) join the group or enroll for coverage after the initial Pathfinder effective date. UNDERWRITING GUIDELINES — Employee-only plans are available for all groups. — If coverage is waived, a qualifying event must occur to gain coverage unless there is an open enrollment. — Dual option plan offerings are not available. — Rates will be separate by geographical area (by employer). — Employees who drop coverage during the year may not re-enroll at anytime unless a qualifying event occurs. — Groups with more than 50% of eligible employees residing outside Minnesota, Nebraska or North Dakota are subject to underwriting review. — Standard coordination of benefits applies. — If the group has less than 2 employees enrolled at the time of renewal, the group will be terminated. — Deductibles and annual maximums are on a calendar-year basis (January through December). — No off-contract changes are allowed. — Dental offices and groups with high turnover or seasonal employment practices are not eligible for coverage. — Coverage is available to family-related groups with 50% or more employees who are related by blood relation, marriage, or adoption. — If 5 or more employees are eligible, but less than 5 are enrolling, we calculate rates according to the 2-4 employee sizeband. Participation guidelines apply according to the number of employees enrolling. PATH.200.13 ORTHODONTICS — OPTIONAL ADD-ON Children — Child orthodontic option available as an add-on for groups of 5 or more enrolled employees. — 12-month waiting period for new groups without prior comparable orthodontic coverage, and for new employees/enrollees. — Coverage for dependent children ages 8 through 18. — Coverage for limited, interceptive, and comprehensive orthodontic treatment. — 50% coverage up to $1,000, $1,500 or $2,000 lifetime maximum. Adults — Adult orthodontics available for groups of 10 or more enrolled employees. — 12-month waiting period for new groups without prior comparable orthodontic coverage, and for new employees/enrollees. — Coverage for limited, interceptive, and comprehensive orthodontic treatment. — 50% coverage up to $1,000 lifetime maximum. Administered and Underwritten by Delta Dental of Minnesota Pathfinder Plan Rates guaranteed for 12 months after issue. Rates Effective January 1, 2014. 5+ Employees Enrolled Monthly premium no ortho ZIP code area Annual Deductible 581 All other ND Single/Family 2-4 Employees Enrolled Monthly premium with ortho* $0/$0 $25/$75 $50/$150 $0/$0 $25/$75 $50/$150 $0/$0 $25/$75 $50/$150 Employee $31.80 $28.65 $27.15 $31.80 $28.65 $27.15 $40.65 $36.65 $34.75 Employee + Spouse $64.80 $58.40 $55.35 $64.80 $58.40 $55.35 N/A N/A N/A Employee + Child(ren) $70.15 $63.25 $59.95 $76.95 $70.05 $66.75 N/A N/A N/A Family — Employee, Spouse, Child(ren) $106.60 $96.15 $91.15 $114.60 $104.15 $99.15 $119.75 $107.95 $102.35 Employee $29.75 $26.90 $25.45 $29.75 $26.90 $25.45 $38.10 $34.40 $32.60 Employee + Spouse $60.75 $54.80 $51.95 $60.75 $54.80 $51.95 N/A N/A N/A Employee + Child(ren) $65.75 $59.35 $56.25 $72.55 $66.15 $63.05 N/A N/A N/A Family — Employee, Spouse, Child(ren) $100.00 $90.20 $85.50 $108.00 $98.20 $93.50 $112.25 $101.25 $96.00 Pathfinder Value Plan Rates guaranteed for 12 months after issue. Rates Effective January 1, 2014. 5+ Employees Enrolled Monthly premium with ortho* Monthly premium no ortho $100 $100 $100 Employee $27.75 $27.75 $35.55 Employee + Spouse $56.65 $56.65 N/A Lifetime Deductible Per Person All other ND 2-4 Employees Enrolled Monthly premium no ortho ZIP code area 581 Monthly premium no ortho Employee + Child(ren) $61.35 $68.15 Family — Employee, Spouse, Child(ren) $93.25 $101.25 $104.70 Employee $26.05 $26.05 $33.35 Employee + Spouse $53.15 $53.15 N/A Employee + Child(ren) $57.55 $64.35 N/A Family — Employee, Spouse, Child(ren) $87.45 $94.25 $98.20 Plan Options Rate Impact $1,250 annual maximum +5% $1,500 annual maximum +9% $2,000 annual maximum** +19% $2,500 annual maximum** +23% $3,000 annual maximum** +26% 2-year rates +3% Increase coverage for composite resin (white) fillings to 80% +5% Increase Endodontics/Periodontal coinsurance to 80% +5% Less than 60% employee participation +10% Family-related groups +12% $1,500 orthodontic lifetime maximum* (groups must have an annual plan maximum of $1,500 or greater) +$2.75 to monthly premium w/ortho for Employee + Child(ren) and Family rates $2,000 orthodontic lifetime maximum* (groups must have an annual plan maximum of $2,000 or greater) +$4.75 to monthly premium w/ortho for Employee + Child(ren) and Family rates Adult orthodontics (available for groups of 10+, $1,000 lifetime maximum, 12-month waiting period) EE – $3.80 • EE+Spouse – $7.60 EE+Child(ren) – $5.05 • Family – $9.20 Remove waiting period +11% ** Available for groups of 5+ with participation of 60% or greater N/A *Orthodontia coverage is for children ages 8 through 18 only, available only for groups of 5 or more enrolled employees. For current rates, please contact Direct Benefits Inc. at 651-649-3503 or (toll-free) 800-620-5010. The Pathfinder Plan is offered exclusively by Direct Benefits Inc. and administered and underwritten by Delta Dental of Minnesota, 500 Washington Ave. S., Minneapolis, MN 55415. Delta Dental is a registered mark of Delta Dental Plans Association (“DDPA”). Delta Dental of Minnesota is an independent nonprofit dental services company and is an authorized licensee of the Delta Dental Plans Association of Oak Brook, Illinois. Direct Benefits Inc. is not an authorized licensee of DDPA. Nothing contained in this statement, or set forth in this document, is in any way meant to imply or suggest that the Pathfinder product or any of Direct Benefits Inc.’s products or services are sponsored, approved, endorsed or recommended by DDPA. 325 Cedar Street, Suite 800 Saint Paul, MN 55101 Phone: 651-649-3503 or 1-800-620-5010 Fax: 651-649-3502 www.directbenefits.com 500 Washington Ave South Suite 2060 Minneapolis, MN 55415-1163 www.deltadentalmn.org Delta Dental PPO Plus Premier – Pathfinder Plan Master Dental Contract Application PART A - COMPANY INFORMATION Legal Company Name Address Phone City State Type of Coverage: Employee Only ( ) Zip Code Employee and Dependents Plan Effective Date: Eligibility probationary period for new employees: First of month following Does your company currently have a dental plan? No Yes (Attach a copy of current billing statement and benefit summary) Other (name of carrier) Length of coverage: Waiting Periods and Takeover Benefits: Waiting Periods Waived for Prior Comparable Coverage If a group has at least 12 continuous months of prior comparable employer paid coverage, and no gap between that coverage and the Pathfinder effective date, all members of the group will receive a waiver of Pathfinder waiting periods, with the following exceptions: The waiver does not apply to employees/dependents who join the group or enroll for Pathfinder coverage after the initial Pathfinder effective date. Credit of $100 Lifetime Deductible If a group has at least 12 continuous months of coverage with a $100 lifetime deductible on its prior dental plan and converts to a Pathfinder plan with a $100 lifetime deductible, members of the group will receive credit for the $100 deductible with the following exceptions: The credit does not apply to employees/dependents who (a) were not enrolled in the group’s prior dental plan or (b) join the group or enroll for coverage after the initial Pathfinder effective date. PART B - PARTICIPATION TOTAL NUMBER OF ELIGIBLE EMPLOYEES __________________ Please check () one below 2-4 Employees Enrolled: One–Time Enrollment – Greater of 2 employees enrolled or 20% of eligible employees and dependents enrolled not covered elsewhere. 5-99 Employees Enrolled: Annual Open Enrollment – Greater of 5 employees enrolled or 20% of eligible employees and dependents not covered elsewhere. Voluntary Program (Pathfinder Flex Plan): Annual Open Enrollment – Group must have 5 or more eligible employees. A minimum of 5 employees must enroll. MEDICAL LOCK (INCLUDE A COPY OF MOST RECENT MEDICAL BILLING STATEMENT) MA-PFDwEHB-Pooled v12/13 PART C – DENTAL PROGRAM (choose one): All programs require completion of a Pathfinder Plan Enrollment Form Rates Sold - Pathfinder Plan/ Pathfinder Value Plan Pathfinder Plan Lifetime Deductible: $50 per person, Diagnostic & Preventive Services only 2-4 Employees Enrolled Annual Plan Deductible for Basic and Major Services only: bPlease check () one below e $0/$0 Single/Family l o $25/$75 Single/Family Single $50/$150 Single/Family Family w 5-99 Employees Enrolled Pathfinder Value Plan Single Single + Spouse __________________ Single + Child(ren) Lifetime Deductible: $100 per person, applies to all services Annual Maximum: Please check () one below Family $1,000 per person/per calendar year $2,000 per person/per calendar year $1,250 per person/per calendar year $2,500 per person/per calendar year $1,500 per person/per calendar year $3,000 per person/per calendar year Increase coverage for Endodontic and Periodontal services to 80% Yes No Is employee participation 60% or greater? Yes No Is group 50% or more related by blood, marriage or adoption? Waive waiting period? Yes Yes No No Please Note: If five or more employees are eligible, but less than five are enrolling, rates and participation guidelines for the number enrolled apply. Pathfinder Flex Plan Rates Sold - Pathfinder Flex Plan Annual Plan Deductible for Basic and Major Services only: $50/$150 Single/Family 5+ Eligible Employees Single Single Single +1 Family Annual Maximum: Please check () one below $1,000 per person/per calendar year $1,500 per person/per calendar year $2,000 per person/per calendar year Is employer contribution 50% or greater? Is group 50% or more related by blood, marriage or adoption? Yes Yes No No Please Note: Minimum of five employees must enroll. PART D - PEDIATRIC DENTAL ESSENTIAL HEALTH BENEFITS The following certified Pediatric Dental Essential Health Benefits (EHB) Plan is available for the Pathfinder Plan and Pathfinder Value Plan: Pediatric Dental EHB Dental Group Plan A (to age 19) PART E - ORTHODONTICS Does the prior dental plan have orthodontic coverage? Yes No Child Orthodontics (For Pathfinder Plan and Pathfinder Value Plan groups with 5 or more enrolled employees; Pathfinder Flex Plan groups with 10 or more enrolled employees): $1,000 Lifetime Orthodontic Maximum $1,500 Lifetime Orthodontic Maximum $2,000 Lifetime Orthodontic Maximum Adult Orthodontics (For Pathfinder Plan and Pathfinder Value Plan groups with 10 or more enrolled employees): $1,000 Lifetime Orthodontic Maximum Please Note: If you are adding orthodontics and the previous dental plan did not have prior, comparable orthodontic coverage, there will be a 12-month waiting period for orthodontic benefits under all Pathfinder plans. MA-PFDwEHB-Pooled v12/13 AGENT OF RECORD (if any) Completion of all fields required Name Agency Address Phone City ( ) State Zip Code E-mail Address Agent Signature / Insurance License ID Number Tax ID Number Note: Commissions will be paid to this TIN. PREMIUM REMITTANCE The first month’s premium must accompany the application. Thereafter, Delta Dental must receive the appropriate remittance on the first of each month. Instructions: 1. Complete Delta Dental PPO Plus Premier – Pathfinder Plan Master Dental Contract Application. 2. Each eligible employee must complete and sign a Pathfinder Plan Membership Enrollment Form or Pathfinder Dental Flex Plan Membership Enrollment Form; or be identified on an approved Enrollment spreadsheet completed by Group Administrator. 3. Send the original Delta Dental PPO Plus Premier – Pathfinder Plan Master Dental Contract Application, completed Pathfinder Plan Enrollment Forms or approved Enrollment Spreadsheet, copy of corresponding Dental Proposal(s), a check for first month of premium payable to Delta Dental, along with current prior carrier billing statement and benefit summary, if applicable, to: Direct Benefits, Inc. 325 Cedar Street, Suite 800 Saint Paul, MN 55101 Please Select Payment Option: ACH Automatic Check Handling - Please note: .25% premium discount for ACH (Include ACH Authorization Form and voided check) Check Wire For questions call (651) 649-3503 or 1-800-620-5010. Group Administrator: By signing below, I verify that the information on this application is correct and that the eligible employees are in fact employed by my company and agree to provide substantiating evidence when requested. If issued, the contract may become null and void at the option of Delta Dental if for a period of three consecutive months, or upon renewal, the number of enrolled employees in Pathfinder Plan or Pathfinder Value Plan becomes less than two, the number of enrolled employees in Pathfinder Flex Plan becomes less than five or contracted participation guidelines are not met. Delta Dental has permission to contact trade and bank references, access commercial and or consumer credit reporting agencies. Delta Dental will return a contract upon acceptance of the application. The contract will indicate the effective date of coverage. The contract is effective only after Delta Dental has accepted this application and sent a contract to the group. The group administrator's signature does not cause the application to become effective as a contract. Any misrepresentations of submitted data will cause the contract, if issued, to be null and void at the option of Delta Dental. SIGNATURE BOX Signature Title Date Please send all future correspondence to: Group Administrator’s Name (please print) Title ( ) Phone Number E-mail Address MA-PFDwEHB-Pooled v12/13 ( ) Fax Number Delta Dental PPO plus Premier- Pathfinder Plan Fully-Insured Groups Automated Clearinghouse Authorization Agreement Company Name authorizes the charge to our bank account through the Automated Clearinghouse (ACH) for the Total Amount Due according to our Invoice / Statement. Premium will be taken on the first business day of each month Group Number ACH Effective Date Bank Name Bank Address Bank Account Number Type of Account Checking Savings Bank Account Name Bank Routing Number (between these symbols on the bottom left of your check) PLEASE INCLUDE A VOIDED CHECK Authorized individual of the Account Print Signature Title Today's Date Telephone Number E:Mail address Questions? Please call our Billing and A/R Department at: 651-406-5902 or 1-800-906-4702 Please complete this form and fax to us at: 1-877-803-2433. or, Please complete this form and mail to: Delta Dental of Minnesota ATTN: Billing and Accounts Receivable P.O. Box 9304 Minneapolis, MN 55440-9304 Delta Dental PPO plus Premier – Pathfinder Plan Membership Enrollment Form Delta Dental of Minnesota PART A – EMPLOYEE INFORMATION – Employee complete Parts A thru E and return form to benefit administrator. Last Employee’s Name: Gender: Male Female First Marital Status: Single Married Middle Initial Widowed Divorced Address Employee’s Address: Social Security Number / / Legally Separated Date of Birth (Month-Day-Year) / / Day Phone Number City State Evening Phone Number Zip Code PART B – ENROLLMENT INFORMATION Select Coverage Type – W ho Is Being Enrolled – Check One Box Only Family Employee only* No Coverage * If waiving coverage for employee and/or any eligible family members, complete Part D. Employee and Spouse Employee and Dependent Child(ren) PART C – DEPENDENT INFORMATION Relationship First Name, Middle Initial, Last Name To Employee (Include Last Name Only if Different From Employee’s) Spouse Domestic Partner Gender Date of Birth Month/Day/Year Full time Student? Unmarried? / / F / / Y N Y N F / / Y N Y N M F Dependent Child M Dependent Child M / / Y N M F Y N PART D – OTHER INSURANCE COVERAGE – Complete if employee and/or eligible dependents are not being enrolled. Yes No Do your dependents have other dental coverage? Yes No Do you (the employee) have other dental coverage? Name of Carrier: ___________________________________ Policy/Identification Number: ______________________________ I waive coverage for myself and/or my dependents and understand that by waiving coverage, whether entirely or partially paid by my employer, that I waive the right to change this selection unless permitted in the group contract’s participation requirements and enrollment restrictions. Delta Dental reserves the right to decline any further enrollment changes. Employee Signature: Date: PART E – EMPLOYEE SIGNATURE – Sign and date form as verification of your enrollment. I am enrolling myself and/or my dependents and authorize payroll deductions, if applicable. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purposes of misleading, information concerning any fact material thereto may commit a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Employee Signature: Date: Dependent Child PART F – GROUP ENROLLMENT INFORMATION - THIS PART TO BE COMPLETED BY EMPLOYER New Group Hire Date: _______/________/________ Prior Coverage Start Date (if applicable): ________/________/________ Coverage Effective Date: ________/________/________ Existing Delta Dental Group Hire Date: _______/________/________ Prior Coverage Start Date (if applicable): ________/________/________ Coverage Effective Date: ________/________/________ New Hire – Apply Probationary Period (if applicable) to determine Effective Date Hire Date: __________ /______/_______ Effective Date:______ /_______/_______ Open Enrollment Effective Date: ______ /_______/_______ Rehire Date Lay Off Began: ________/________/_______ Date Rehired: ________/________/_______ Return from Leave of Absence Date Leave Began: ________/________/________ Date Returned to Work: ________/________/________ Employee Change Part Time to Full Time Date of Status Change: ________ /________/________ Effective Date: ________ /________/________ Previously Waived Coverage or Loss of Coverage Qualifying Event Reason:_________________________________ Hire Date: _____________ /_______/________ Event Date: ___________ /_______/________ Effective Date: ________ /_______/________ Group Name: Group & Subgroup Numbers: Group Representative’s Signature: Date: Phone Number: Send Original Copy to Delta Dental Retain Copy For Your Records E11 11.18.2013 Employer Instructions • Review Parts A, B, C, D, and E to assure the employee provided complete, accurate and legible information. st • When reporting effective dates use contractual start and stop guidelines as defined in your contract (i.e., 1 of month, end of month, or actual dates). • Delta Dental of Minnesota generally completes enrollment requests within five business days of receipt. Complete Part F - Group Enrollment Information • Check one reason for enrollment and provide requested information including coverage effective dates. • New Group – New customer to Delta Dental and submitting initial employee enrollment. Complete the Prior Coverage Start Date only if your plan benefits include waiting periods and credit for prior creditable coverage applies. Note: For a New Group enrolling a Direct Billed COBRA participant, write Direct Bill in the New Group section. If information is not provided, participant will not be enrolled and billed properly. • Existing Delta Dental Group – Enrolling additional employees from an acquisition/merger who were not previously offered/enrolled in you Delta Dental plan. Complete the Prior Coverage Start Date only if your plan benefits include waiting periods and credit for prior creditable coverage applies. • New Hire – Enroll newly hired employee. If a probationary period applies, the coverage effective date is after the probationary period. • Open Enrollment – An employee is enrolling during group’s open enrollment period. • Rehire – A former employee was rehired. • Return From Leave of Absence – An employee is returning from leave of absence. • Employee Status Change – The employee’s employment status changed and the employee is now eligible for dental benefits. • Previously Waived Coverage or Loss of Coverage – If an employee waives coverage, he/she can only enroll at a later date if the group contract includes an Open Enrollment period or if the individual has a loss of other insurance coverage. If an employee or dependent involuntarily losses coverage and are now eligible to enroll, complete this section. • Group Name – Provide group name as listed in your contract. • Group and Subgroup Number – Provide applicable numbers for individual employee. • Group Representative – Sign, date, and provide your phone number. Send Completed Forms To: Delta Dental of Minnesota Attn: Enrollment Department PO Box 330 Minneapolis MN 55440-0330 Checklist for Pathfinder Plan New Group Submissions The following is a checklist of the required materials when submitting a new Pathfinder Plan group for implementation: 4. Enrollment forms for ALL benefit eligible employees (including waivers) Waivers must include name, marital status, address and Part D – other coverage information for employee and/or eligible dependents 1. 1st month’s premium check made payable to DELTA DENTAL If you have any questions, please contact Jessica Traiforos at 651-259-6256 or Jessica@directbenefits.com. Submissions should be mailed to the following address: 2. Completed Master Application – State specific . Group Name, Address & Phone Number . Type of coverage (available for Employees Only or Employees & dependents) . Effective Date of coverage . Probationary Period for new employees . Current coverage information & documentation for take-over (last billing statement and schedule of benefits) . Total Number of Eligible Employees & participation size-band marked . If Medical Lock -copy of medical billing . Complete all areas of Part C (Deductible, Annual Maximum, Endo/Perio coverage, Employee Participation, etc.) . Sold Rates (provide a copy of an agent generated quote from our website: http://www.directbenefits.com/deltapathfinder-mn-nd-a-ne-dental) . Part D Orthodontics, if electing, indicate the Lifetime Maximum . Completed & Signed Agent of Record Section . Premium Remittance (ACH or Monthly Billing) . If electing ACH -completed & signed ACH Authorization Form & copy of a voided check . Group Administrator Signature & Group Correspondence contact information Attn: Jessica Traiforos Direct Benefits, Inc. 325 Cedar Street Suite 800 Saint Paul MN 55101 3. Underwriting Guidelines . Required participation is being met for requested product & size band . If electing $2,000 Annual Max, 5+ enrolled & 60% or greater participation . If Orthodontics is elected, required participation is being met . Pathfinder Enrollment Forms Direct Benefits Inc. • 325 Cedar Street • Suite 800 • St Paul, MN 55101 www.directbenefits.com